Personality disorder cases (diagnosis)

X is the enduring pattern of behaviour and inner experience. X underlies how we think, feel, and act and frames how we view ourselves and the people around us. When we think of who we are, we often think of X as the central defining characteristic. What is X?

Personality

Case. What is your diagnosis? Ogden Judd and his boyfriend, Peter Kleinman, presented for couples therapy to address escalating conflict around the issue of moving in together. Mr. Kleinman described a several-month-long apartment search that was made "agonizing" by Mr. Judd's rigid work schedule and his "endless" list of apartment demands. They were unable to come to a decision, and eventually they decided to just share Mr. Judd's apartment. As Mr. Kleinman concluded, "Ogden won." Mr. Judd refused to hire movers for his boyfriend's belongings, insisting on personally packing and taking an inventory of every item in his boyfriend's place. What should have taken 2 days took 1 week. Once the items were transported to Mr. Judd's apartment, Mr. Kleinman began to complain about Mr. Judd's "crazy rules" about where items could be placed on the bookshelf, which direction the hangers in the closet faced, and whether their clothes could be intermingled. Moreover, Mr. Kleinman complained that there was hardly any space for his possessions because Mr. Judd never threw anything away. "I'm terrified of losing something important," added Mr. Judd. Over the ensuing weeks, arguments broke out nightly as they unpacked boxes and settled in. Making matters worse, Mr. Judd would often come home after 9:00 or 10:00 p.m., because he had a personal rule to always have a blank "to-do" list by the end of the day. Mr. Kleinman would often wake early in the morning to find Mr. Judd grimly organizing shelves or closets or sorting books alphabetically by author. Throughout this process, Mr. Judd appeared to be working hard at everything while enjoying himself less and getting less done. Mr. Kleinman found himself feeling increasingly detached from his boyfriend the longer they lived together. Mr. Judd denied symptoms of depression and free-floating anxiety. He said that he had never experimented with cigarettes or alcohol, adding, "I wouldn't want to feel like I was out of control." He denied a family history of mental illness. He was raised in a two-parent household and was an above average high school and college student. He was an only child and first shared a room as a college freshman. He described that experience as being difficult due to "conflicting styles—he was a mess and I knew that things should be kept neat." He had moved mid-year into a single dorm room and had not lived with anyone until Mr. Kleinman moved in. Mr. Judd was well liked by his boss, earning recognition as "employee of the month" three times in 2 years. Feedback from colleagues and subordinates was less enthusiastic, indicating that he was overly rigid, perfectionistic, and critical. On examination, Mr. Judd was a thin man with eyeglasses and gelled hair, sitting on a couch next to his boyfriend. He was meticulously dressed. He was cooperative with the interview and sat quietly while his boyfriend spoke, interrupting on a few occasions to contradict. His speech was normal in rate and tone. His affect was irritable. There was no evidence of depression. He denied specific phobias and did not think he had ever experienced a panic attack. At the end of the consultation, Mr. Judd remarked, "I know I'm difficult, but I really do want this to work out."

Obsessive-compulsive personality disorder is characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human resources department of a large construction business that had been his employer for 2 weeks. At his initial job interview, Mr. Crocker presented as very motivated and provided two carpentry school certifications that indicated a high level of skill and training. Since his employment began, his supervisors had noted frequent arguments, absenteeism, poor workmanship, and multiple errors that might have been dangerous. When confronted, he was reportedly dismissive, indicating that the problem was "cheap wood" and "bad management" and added that if someone got hurt, "it's because of their own stupidity." When the head of human resources met with him to discuss termination, Mr. Crocker quickly pointed out that he had both attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder. He said that if not granted an accommodation under the Americans with Disabilities Act, he would sue. He demanded a psychiatric evaluation. During the mental health evaluation, Mr. Crocker focused on unfairness at the company and on how he was "a hell of a better carpenter than anyone there could ever be." He claimed that his two marriages had ended because of jealousy. He said that his wives were "always thinking I was with other women," which is why "they both lied to judges and got restraining orders saying I'd hit them." As "payback for the jail time," he refused to pay child support for his two children. He had no interest in seeing either of his two boys because they were "little liars" like their mothers. Mr. Crocker said he "must have been smart" because he had been able to make Cs in school despite showing up only half the time. He spent time in juvenile hall at age 14 for stealing "kid stuff, like tennis shoes and wallets that were practically empty." He left school at age 15 after being "framed for stealing a car" by his principal. Mr. Crocker pointed out these historical facts as evidence that he was able to overcome injustice and adversity. In regard to substance use, Mr. Crocker said he smoked marijuana as a teenager and started drinking alcohol on a "regular basis" after he first got married at age 22. He denied that use of either substance was a problem. Mr. Crocker concluded the interview by demanding a note from the examiner that he had "bipolar" and "ADHD." He said that he was "bipolar" because he had "ups and downs" and got "mad real fast." Mr. Crocker denied other symptoms of mania. He said he got down when disappointed, but he had "a short memory" and "could get out of a funk pretty quick." Mr. Crocker reported no difficulties in his sleep, mood, or appetite. He learned about ADHD because "both of my boys got it." He concluded the interview with a request for medications, adding that the only ones that worked were stimulants ("any of them") and a specific short-acting benzodiazepine. On mental status examination, Mr. Crocker was a casually dressed white man who made reasonable eye contact and was without abnormal movements. His speech was coherent, goal directed, and of normal rate. There was no evidence of any thought disorder or hallucinations. He was preoccupied with blaming others, but these comments appeared to represent overvalued ideas rather than delusions. He was cognitively intact. His insight into his situation was poor. The head of human resources did a background check during the course of the psychiatric evaluation. Phone calls revealed that Mr. Crocker had been expelled from two carpentry training programs and that both his graduation certificates had been falsified. He had been fired from his job at one local construction company after a fistfight with his supervisor and from another job after abruptly leaving a job site. A quick review of their records indicated that he had provided them with the same false documentation.

Antisocial personality disorder. is characterized by a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years. Ddx: Mr. Crocker's interpersonal style is marked by callous disregard for the feelings of others and an arrogant self-appraisal. Such qualities can be found in other personality disorders, such as narcissistic personality disorder, but they are also common in APD. Although comorbidity is not uncommon, individuals with narcissistic personality disorder do not exhibit the same levels of impulsivity, aggression, and deceit as are present in APD. Individuals with histrionic personality disorder or borderline personality disorder may be manipulative or impulsive, but their behaviors are not characteristically antisocial. Individuals with paranoid personality disorder may demonstrate antisocial behaviors, but their actions tend to stem from a paranoid desire for revenge rather than a desire for personal gain. Finally, people with intermittent explosive disorder also get into fights, but they lack the many exploitive traits that are a pervasive part of APD. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Mathilda Herbert was a 23-year-old woman referred for psychiatric consultation to help her "break out of her shell." She had recently moved to a new city to take classes to become an industrial lab technician and had moved in with an older cousin, who was also a psychotherapist and thought she should "get out and enjoy her youth." Although she had previously been prescribed medications for anxiety, Ms. Herbert said that her real problem was "shyness." School was difficult because everyone was constantly "criticizing." She avoided being called on in class because she knew she would "say something stupid" and blush and everyone would make fun of her. She avoided speaking up or talking on telephones, worried about how she would sound. She dreaded public speaking. She was similarly reticent with friends. She said she had always been a people pleaser who preferred to hide her feelings with a cheerful, compliant, attentive demeanor. She had a few friends, whom she described as "warm and lifelong." She felt lonely after her recent move and had not yet met anyone from school or the local community. She said she had broken up with her first serious boyfriend 2 years earlier. He had initially been "kind and patient" and, through him, she had a social life by proxy. Soon after she moved in with him, however, he turned out to be an "angry alcoholic." She had not dated since that experience. Ms. Herbert grew up in a metropolitan area with her parents and three older siblings. Her brother was "hyperactive and antisocial" and took up everyone's attention, whereas her sisters were "hypercompetitive and perfect." Her mother was anxiously compliant, "like me." Ms. Herbert's father was a very successful investment manager who often pointed out ways in which his children did not live up to his expectations. He could be supportive but tended to disregard emotional uncertainty in favor of a "tough optimism." Teasing and competition "saturated" the household, and "it didn't help that I was forced to go to the same girls' school where my sisters had been stars and where everyone was rich and catty." She developed a keen sensitivity to criticism and failure. Her parents divorced during her senior year of high school. Her father married another woman soon thereafter. Although she had planned to attend the same elite university as her two sisters, she chose to attend a local community college at the last minute. She explained that it was good to be away from all the competition, and her mother needed the support. Ms. Herbert's strengths included excellent work in her major, chemistry, especially after one senior professor took a special interest. Family camping trips had led to a mastery of outdoor skills, and she found that she enjoyed being out in the woods, flexing her independence. She also enjoyed babysitting and volunteering in animal shelters, because kids and animals "appreciate everything you do and aren't mean." During the evaluation, Ms. Herbert was a well-dressed young woman of short stature who was attentive, coherent, and goal directed. She smiled a lot, especially when talking about things that would have made most people angry. When the psychiatrist offered a trial comment, linking Ms. Herbert's current anxiety to experiences with her father, the patient appeared quietly upset. After several such instances, the psychiatrist worried that any interpretive comments might be taken as criticism and had to check a tendency to avoid sensitive subjects. Explicitly discussing his concerns led both the patient and psychiatrist to relax and allowed the conversation to continue more productively.

Avoidant PD Social anxiety disorder (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Juanita Delgado, a single, unemployed Hispanic woman, sought therapy at age 33 for treatment of depressed mood, chronic suicidal thoughts, social isolation, and poor personal hygiene. She had spent the prior 6 months isolated in her apartment, lying in bed, eating junk food, watching television, and doing more online shopping than she could afford. Multiple treatments had yielded little effect. Ms. Delgado was the middle of three children in an upper-middle-class immigrant family in which the father reportedly valued professional achievement over all else. She felt isolated throughout her school years and experienced recurrent periods of depressed mood. Within her family, she was known for angry outbursts. She had done well academically in high school but dropped out of college because of frustrations with a roommate and a professor. She attempted a series of internships and entry-level jobs with the expectation that she would return to college, but she kept quitting because "bosses are idiots. They come across as great and they all turn out to be twisted." These "traumas" always left her feeling terrible about herself ("I can't even succeed as a clerk?") and angry at her bosses ("I could run the place and probably will"). She had dated men when she was younger but never let them get close physically because she become too anxious when any intimacy began to develop. Ms. Delgado's history included cutting herself superficially on a number of occasions, along with persistent thoughts that she would be better off dead. She said that she was generally "down and depressed" but that she had had dozens of 1- to 2-day "manias" in which she was energized and edgy and pulled all-nighters. She tended to "crash" the next day and sleep for 12 hours. She had been in psychiatric treatment since age 17 and had been psychiatrically hospitalized three times after overdoses. Treatments had consisted primarily of medication: mood stabilizers, low-dose neuroleptics, and antidepressants that had been prescribed in various combinations in the context of supportive psychotherapy. During the interview, she was a casually groomed and somewhat unkempt woman who was cooperative, coherent, and goal directed. She was generally dysphoric with a constricted affect but did smile appropriately several times. She described shame at her poor performance but also believed she was "on Earth to do something great." She described her father as a spectacular success, but he was also a "Machiavellian loser who was always trying to manipulate people." She described quitting jobs because people were disrespectful. For example, she said that when she worked as a clerk at a department store, people would often be rude or unappreciative ("and I was there only in preparation to become a buyer; it was ridiculous"). Toward the end of the initial session, she became angry with the interviewer after he glanced at the clock ("Are you bored already?"). She said she knew people in the neighborhood, but most of them had "become frauds or losers." There were a few people from school who were "Facebook friends," doing amazing things all over the world. Although she had not seen them in years, she intended to "meet up with them if they ever come back to town."

Borderline personality disorder. Depression is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case What is your diagnosis? Nate Irvin was a 31-year-old white man who sought outpatient psychiatric services for "lack of self-confidence." He reported lifelong troubles with assertiveness and was specifically upset by having been "stuck" for 2 years at his current "dead-end" job as an administrative assistant. He wished someone would tell him where to go next so that he would not have to face the "burden" of decision. At work, he found it easy to follow his boss's directions but had difficulty making even minor independent decisions. The situation was "depressing," he said, but nothing new. Mr. Irvin also reported dissatisfaction with his relationships with women. He described a series of several-month-long relationships over the prior 10 years that ended despite his doing "everything I could." His most recent relationship had been with an opera singer. He reported having gone to several operas and taken singing classes to impress her, even though he did not particularly enjoy music. That relationship had recently ended for unclear reasons. He said his mood and self-confidence were tied to his dating. Being single made him feel desperate, but desperation made it even harder to get a girlfriend. He said he felt trapped by that spiral. Since the latest breakup, he had been quite sad, with frequent crying spells. It was this depression that had prompted him to seek treatment. He denied all other symptoms of depression, including problems with sleep, appetite, energy, suicidality, and ability to enjoy things. Mr. Irvin initially denied taking any medications, but he eventually revealed that 1 year earlier his primary care physician had begun to prescribe alprazolam 0.5 mg/day for "anxiety." His dose had escalated, and at the time of the evaluation, Mr. Irvin was taking 5 mg/day and getting prescriptions from three different physicians. Cutting back led to anxiety and "the shakes." Mr. Irvin denied any prior personal or family psychiatric history, including outpatient psychiatric appointments. After hearing this history, the psychiatrist was concerned about Mr. Irvin's escalating alprazolam use and his chronic difficulties with independence. She thought the most accurate diagnosis was benzodiazepine use disorder comorbid with a personality disorder. However, she was concerned about the negative unintended effects that these diagnoses might have on the patient, including his employment and insurance coverage, as well as how he would be dealt with by future clinicians. She typed into the electronic medical record a diagnosis of "adjustment disorder with depressed mood." Two weeks later, Mr. Irvin's insurance company asked her his diagnosis, and she gave the same diagnosis.

Dependent personality disorder Benzodiazepine use disorder Note (re: disclosure): When diagnoses are inaccurately recorded in medical charts, ostensibly for the purpose of protecting patients, this may end up causing harm instead. Subsequent clinicians who review the records may lack critical information regarding patients' presentation and treatment. Lack of disclosure is tantamount to fraud and can be prosecuted. In addition, although being part of the medical profession affords many privileges, it also involves responsibilities. Diagnostic deceit may seem like an innocuous effort to protect the patient, but the dishonesty negatively affects the reputation of the entire profession, a reputation that is integral to the ability to render treatment to future patients. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Karmen Fuentes was a 50-year-old married Hispanic woman who presented to the psychiatric emergency room (ER) at the urging of her outpatient psychiatrist after telling him that she had been thinking about overdosing on Advil. In the ER, Ms. Fuentes explained that her back had been "killing" her since she fell several days earlier at the family-owned grocery store where she had worked for many years. The fall had left her downcast and depressed, although she denied other depressive symptoms aside from a poor mood. She spoke at length about the fall and about how it reminded her of a fall that she had sustained a few years earlier. At that time, she had gone to see a neurosurgeon, who told her to rest and take nonsteroidal anti-inflammatory drugs. She described feeling "abandoned and not cared about" by him. The pain had diminished her ability to exercise, and she was upset that she had gained weight. While relating the events surrounding the fall, Ms. Fuentes began to cry. When asked about her suicidal comments, she said they were "no big deal." She reported that they were "just a threat" aimed at her husband to "teach him a lesson" because "he has no compassion for me" and had not been supportive since the fall. She insisted her comments about overdosing did not have other meaning. When her ER interviewer expressed concern about the possibility that she would kill herself, she exclaimed with a smile, "Oh wow, I didn't realize it's so serious. I guess I shouldn't do that again." She then shrugged and laughed. She went on to talk about how "nice and sweet" it was that so many doctors and social workers wanted to hear her story, calling many of them by their first names. She was also somewhat flirtatious with her male resident interviewer, who had mentioned that she was the "best-dressed woman in the ER." According to her outpatient psychiatrist of 3 years, she had never before expressed suicidal ideation until this week, and he would be unable to check in on her until after he left on vacation the next day. Ms. Fuentes's husband reported that she talked about suicide "like other people complain about the weather. She's just trying to get me worried, but it doesn't work anymore." He said he would never have suggested she go to the ER and thought the psychiatrist had overreacted. Ms. Fuentes initially sought outpatient psychotherapy at age 47 because she was feeling depressed and unsupported by her husband. During 3 years of outpatient treatment, Ms. Fuentes had been prescribed adequate trials of sertraline, escitalopram, fluoxetine, and paroxetine. None seemed to help. Ms. Fuentes described being "an early bloomer." She became sexually active with older men when she was in high school. She said dating had been the most fun thing she had ever done and that she missed seeing men "jump through hoops" to sleep with her. She lived with her 73-year-old husband. Her 25-year-old son lived nearby with his wife and young son. She described her husband as a "very famous" musician. She said that he had never helped around the house or with child-rearing and did not appreciate how much work she put into taking care of their son and grandson.

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. vs Borderline PD Ms. Fuentes's suicidal threats and dramatic presentation might lead the examiner to consider borderline personality disorder. Ms. Fuentes does not, however, show the marked instability in interpersonal relationships, extreme self-destructiveness, angry disruptions in interpersonal relationships, and chronic feelings of emptiness that are common in borderline personality disorder. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Larry Goranov was a 57-year-old single unemployed white man who was asking for a review of his treatment at the psychiatric clinic. He had been in weekly psychotherapy for 7 years with a diagnosis of dysthymic disorder. He complained that the treatment had been of little help and he wanted to make sure that the doctors were on the right track. Mr. Goranov reported a long-standing history of low-grade depressed mood and decreased energy. He had to "drag" himself out of bed every morning and rarely looked forward to anything. He had lost his last job 3 years earlier, had broken up with a girlfriend slightly later, and doubted that he would ever work or date again. He was embarrassed that he still lived with his mother, who was in her 80s. He denied any immediate intention or plan to kill himself, but if he did not improve by the time his mother died, he did not see what he would have to live for. He denied disturbances in sleep, appetite, or concentration. Clinic records indicated that Mr. Goranov had been adherent to adequate trials of fluoxetine, escitalopram, sertraline, duloxetine, venlafaxine, and bupropion, as well as augmentation with quetiapine, aripiprazole, lithium, and levothyroxine. He had some improvement in his mood while taking escitalopram but did not have remission of symptoms. He also had a course of cognitive-behavioral therapy early in his treatment; he had been dismissive of the therapist and treatment, did not do his assigned homework, and appeared to make no effort to use the therapy between sessions. He had never tried psychodynamic psychotherapy. Mr. Goranov expressed frustration at his lack of improvement, the nature of his treatment, and his specific therapy. He found it "humiliating" that he was forced to see trainees who rotated off his case every year or two. He frequently found that the psychiatry residents were not especially educated, cultured, or sophisticated, and felt they knew less about psychotherapy than he did. He much preferred to work with female therapists, because men were "too competitive and envious." Mr. Goranov previously worked as an insurance broker. He explained, "It's ridiculous. I was the best broker they had ever seen, but they won't rehire me. I think the problem is that the profession is filled with big egos, and I can't keep my mouth shut about it." After being "blackballed" by insurance agencies, Mr. Goranov did not work for 5 years, until he was hired by an automobile dealer. He said that although it was beneath him to sell cars, he was successful, and "in no time, I was running the place." He quit within a few months after an argument with the owner. Despite encouragement from several therapists, Mr. Goranov had not applied for a job or pursued employment rehabilitation or volunteer work; he strongly viewed these options as beneath him. Mr. Goranov has "given up on women." He had many partners as a younger man, but he generally found them to be unappreciative and "only in it for the free meals." The psychiatric resident notes indicated that he responded to demonstrations of interest with suspicion. This tendency held true in regard to both women who had tried to befriend him and residents who had taken an interest in his care. Mr. Goranov described himself as someone who had a lot of love to give, but said that the world was full of manipulators. He said he had a few buddies, but his mother was the only one he truly cared about. He enjoyed fine restaurants and "five-star hotels," but he added that he could no longer afford them. He exercised daily and was concerned about maintaining his body. Most of his time was spent at home watching television or reading novels and biographies. On examination, the patient was neatly groomed, had slicked-back hair, and wore clothing that appeared to be by a hip-hop designer generally favored by men in their 20s. He was coherent, goal directed, and generally cooperative. He said he was sad and angry. His affect was constricted and dismissive. He denied an intention to kill himself but felt hopeless and thought of death fairly often. He was cognitively intact.

Narcissistic PD is characterized by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Frazier Archer was a 34-year-old single white man who called a mood and personality disorders research program because an ex-friend had once said he was "borderline," and Mr. Archer wanted to learn more about his personality conflicts. During his diagnostic research interviews, Mr. Archer reported regular, almost daily situations in which he was sure he was being lied to or deceived. He was particularly wary of people in leadership positions and people who had studied psychology and, therefore, had "training to understand the human mind," which they used to manipulate people. Unlike those around him, Mr. Archer believed he did not "drink the Kool-Aid" and was able to detect manipulation and deceit. Mr. Archer was extremely detail oriented at work, and had trouble delegating and completing tasks. Numerous employers had told him that he focused excessively on rules, lists, and small details, and that he needed to be more friendly. He had held numerous jobs over the years, but he was quick to add, "I've quit as often as I've been fired." During the interview, he defended his behavior, asserting that unlike many people, he understood the value of quality over productivity. Mr. Archer's wariness had contributed to his "bad temper" and emotional "ups and downs." He socialized only "superficially" with a handful of acquaintances and could recall the exact moments when previous "so-called friends and lovers" had betrayed him. He spent most of his time alone. Mr. Archer denied any significant history of trauma, any current or past problems with substance use, and any history of head trauma or loss of consciousness. He also denied any history of mental health diagnosis or treatment, but reported that he felt he might have a mental health condition that had not yet been diagnosed. On mental status examination, Mr. Archer appeared well groomed, cooperative, and oriented. His speech varied; at times he would pause thoughtfully prior to answering questions, causing his rate of speech to be somewhat slow. His tone also changed significantly when he discussed situations that had made him angry, and many of his responses were lengthy, digressive, and vague. However, he seemed generally coherent and did not evidence perceptual disorder. His affect was occasionally inappropriate (e.g., smiling while crying) but generally constricted. He reported apathy as to whether he lived or died but did not report any active suicidal ideation or homicidal ideation. Notably, Mr. Archer became irritated and argumentative with research staff when he was told that although he could receive verbal feedback on his interviews, he could not receive a copy of completed questionnaires and diagnostic tools. He commented that he would document in his personal records that research staff were refusing him the forms.

Paranoid personality disorder (PPD) Obsessive-compulsive personality disorder (OCPD) (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985) PPD is characterized by pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. OCPD is is characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

Case What is your diagnosis? Grzegorz Buchalski was an 87-year-old white man who was brought to the psychiatric emergency room (ER) by paramedics after they had been called to his apartment by neighbors when they noticed an odd smell. Apparently, his 90-year-old sister had died some days earlier after a lengthy illness. Mr. Buchalski had delayed reporting her death for several reasons. He had become increasingly disorganized as his sister's health had worsened, and he was worried that his landlord would use the apartment's condition as a pretext for eviction. He had tried to clean up, but his attempts consisted mainly of moving items from one place to another. He said he was about to call for help when the police and paramedics showed up. In the ER, Mr. Buchalski recognized that his actions were odd and that he should have called for help sooner. At times, he became tearful when discussing the situation and his sister's death; at other times, he seemed aloof, speaking about these in a calm, factual way. He also wanted to clarify that his apartment had indeed been a mess but that much of the apparent mess was actually his large collection of articles on bioluminescence, a topic he had been researching for decades. A licensed plumber, electrician, and locksmith, Mr. Buchalski had worked until age 65. He described his late sister as having been always "a little strange." She had never worked and had been married once, briefly. Aside from the several-month marriage, she and Mr. Buchalski had lived in the family's two-bedroom Manhattan apartment their entire lives. Neither of them had ever seen a psychiatrist. When questioned, Mr. Buchalski stated that he had never had a romantic or sexual relationship and had never had many friends or social contacts outside his family. He explained that he had been poor and Polish and had had to work all the time. He had taken night classes to better understand "the strange world we live in," and he said his intellectual interests were what he found most gratifying. He said he had been upset as he realized that his sister was dying, but he would call it "numb" rather than depressed. He also denied any history of manic or psychotic symptoms. After an hour with the psychiatric trainee, Mr. Buchalski confided that he hoped the medical school might be interested in some of his papers after his death. He said he believed that bioluminescent and genetic technologies were on the verge of a breakthrough that might allow the skin of animals and then humans to glow in subtle colors that would allow people to more directly recognize emotions. He had written the notes for such technology, but they had grown into a "way-too-long science fiction novel with lots of footnotes." On examination, Mr. Buchalski was a thin, elderly man dressed neatly in khakis and button-down shirt. He was meticulous and much preferred to discuss his interests in science than his own story. He made appropriate eye contact and had a polite, pleasant demeanor. His speech was coherent and goal directed. His mood was "fine," and his affect was appropriate though perhaps unusually cheerful under the circumstances. He denied all symptoms of psychosis, depression, and mania. Aside from his comments about bioluminescence, he said nothing that sounded delusional. He was cognitively intact, and his insight and judgment were considered generally good, although historically impaired in regard to his delay in calling the police about his sister.

Schizoid personality disorder. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings versus schizotypal personality disorder, which is characterized by cognitive and perceptual disturbances in addition to the social isolation. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)

Case. What is your diagnosis? Henry, a 19-year-old college sophomore, was referred to the student health center by a teaching assistant who noticed that he appeared odd, worried, and preoccupied and that his lab notebook was filled with bizarrely threatening drawings. Henry appeared on time for the psychiatric consultation. Although suspicious about the reason for the referral, he explained that he generally "followed orders" and would do what he was asked. He agreed that he had been suspicious of some of his classmates, believing they were undermining his abilities. He said they were telling his instructors that he was "a weird guy" and that they did not want him as a lab partner. The referral to the psychiatrist was, he said, confirmation of his perception. Henry described how he had seen two students "flip a coin" over whether he was gay or straight. Coins, he asserted, could often predict the future. He had once flipped a coin and "heads" had predicted his mother's illness. He believed his thoughts often came true. Henry had transferred to this out-of-town university after an initial year at his local community college. The transfer was his parents' idea, he said, and was part of their agenda to get him to be like everyone else and go to parties and hang out with girls. He said all such behavior was a waste of time. Although they had tried to push him into moving into the dorms, he had refused, and instead lived by himself in an off-campus apartment. With Henry's permission, his mother was called for collateral information. She said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, had never dated, and had denied wanting to have friends. He acknowledged feeling depressed and anxious at times, but these feelings did not improve when he was around other people. He was teased by other kids and would come home upset. His mother cried while explaining that she always felt bad for him because he never really "fit in," and that she and her husband had tried to coach him for years without success. She wondered how a person could function without any social life. She added that ghosts, telepathy, and witchcraft had fascinated Henry since junior high school. He had long thought that he could change the outcome of events like earthquakes and hurricanes by thinking about them. He had consistently denied substance abuse, and two drug screens had been negative in the prior 2 years. She mentioned that her grandfather had died in an "insane asylum" many years before Henry was born, but she did not know his diagnosis. On examination, Henry was tall, thin, and dressed in jeans and a T-shirt. He was alert and wary and, although nonspontaneous, he answered questions directly. He denied feeling depressed or confused. Henry denied having any suicidal thoughts, plans, or attempts. He denied having any auditory or visual hallucinations, panic attacks, obsessions, compulsions, or phobias. His intellectual skills seemed above average, and his Mini-Mental State Examination score was 30 out of 30.

Schizotypal personality disorder. Paranoid personality disorder. is characterized by a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour. (For discussion of case, see http://dsm.psychiatryonline.org.proxy.lib.nosm.ca/doi/full/10.1176/appi.books.9781585624836.jb18#x97847.8294985)